RUMAH SAKIT

MURNI TEGUH
CILEDUG
Jl. HOS. Cokroaminoto (Ciledug Raya) No. 4A,
Kreo Selatan - Larangan, Tangerang 15156
Telp. 7371919 (Hunting), Fax No. 7371333
Unit Gawat Darurat 7371818

No. Urut :

SURAT JALAN KENDARAAN UMUM

No. Kendaraan : .............................

Nama Pengguna : .........................................................................................................

Jabatan : .........................................................................................................
Unit : .........................................................................................................
Keperluan : .........................................................................................................
.........................................................................................................
Pengguna Lain : 1.................................. 2 .................................. 3..........................
4.................................. 5 ................................... 6..........................
Berangkat Pukul : ......................................... Km : ......................................................
Kembali Pukul : ......................................... Km : ......................................................
Tujuan : .........................................................................................................
.........................................................................................................
Nama Pengemudi : .........................................................................................................

Tangerang, ................................. 20 .........

Mengetahui,

Ka. ................ Keamanan Pengemudi Pemohon

( .......................... ) ( .......................... ) ( .......................... ) ( .......................... )

K.UM-12
 RUMAH SAKIT No. Lab :
MURNI TEGUH Jl. HOS Cokroaminoto ( Ciledug Raya ) No. 4A Kreo Selatan - Larangan, Tangerang 15156
CILEDUG Telp. 737 1919 (Hunting), Fax 021 - 737 1333, Unit Gawar Darurat 7371818

PERMINTAANPEMERIKSAAN LABORATORIUM RAWAT JALAN

Nama : .................................................................. Tgl Permintaan : ................/ ............./ .............

Tgl. Lahir : .................................. Jenis Kelamin L / P Dokter Pengirim : ..............................................

No. RM : .................................. No. Reg : .................................... Ruangan : ..............................................

Diagnosa / keterangan Klinis (Harap diisi) :
Pemeriksaan yang diminta harap diberi tanda (x)

HEMATOLOGI LEMAK DARAH AUTO IMUN TORCH MIKROBIOLOGI

[ ] Darah Rutin 1 [ ] Cholesterol Total)* [ ] ANA [ ] HSV l lg G Bahan ........................................
[ ] HSV l lg M (Tulis sampel yang dikehendaki)
(Hb. Ht. Leuko, trombo) [ ] Cholesterol HDL )* [ ] Anti ds DNA
[ ] Pewarnaan Gram
[ ] Darah Rutin 2 [ ] Trigliserida )* [ ] ASTO Kualitatif [ ] HSV ll lg G
[ ] Pewarnaan BTA Pagi - Sewaktu
(Ruti) 1.Index Ery,Ery,Dift) [ ] Total Lipid )* [ ] ASTO Semi Kuantitatif [ ] HSV ll lg M
[ ] Prapat GO
[ ] Darah Lengkap [ ] [ ] CRP Kualitatif [ ] Toxoplasma lg G Aviditas
[ ] Pemeriknan Sekret
(Rutin 2, LEO) FUNGSI GINJAL [ ] CRP Semi Kuantitatif
PENANDA TUMOR [ ] Kultur & Resistensi
[ ] Index Eritrosit [ ] Ureum [ ] RF Kualitatif [ ] ACP
(MCV,MCH,MCHC) [ ] Creatinine [ ] RF Semi Kuantitatif [ ] ADA PAKET
[ ] Hitung Jenis Lekosit / Dift [ ] Asam Urat)* [ ] C3 Cornplemen [ ] AFP [ ] Paket Hemostasis
[ ] Eritrosit [ ] CCT )** [ ] C4 Complemen [ ] CA 125 (Ovarium) (APTT+PT+Fibrinogen+
[ ] Hitung Eosinol Total [ ] Cystatin C [ ] lg A [ ] CA 15-3 (Payudara) D Dimer)
[ ] Laju Endap Darah (LED) [ ] lg M
FUNGSI HATI [ ] CA 19 9 (Pankreas) [ ] Paket LFT (Liver Fungsi Tes)
[ ] Gambaran Darah Tepi [ ] lg G
[ ] SGOT/SGPT [ ] CA 72-4 (Bilirubin lengkap+
[ ] Golongan darah / Rhesus INFEKSI LAIN
[ ] Total Protein [ ] CEA Protein Lengkap + Alkali
[ ] Retikulosit [ ] Widal
[ ] Albumin [ ] Cyfra 21-1 Phospatase + Gamma GT +
[ ] Malaria (Slide) [ ] Serologi Jamur
[ ] Protein Lengkap [ ] Free PSA SGOT+SGPT)
[ ] Malaria (Rapid) [ ] Ns1 Ag
[ ] (Total+Albumin+Globulin) [ ] PAP [ ] Paket RFT (Renal Fungsi Test)
[ ] Mikrolaria [ ] Anti Dengue lg G/lg M
[ ] Bilirubin Total [ ] PSA (Ureum,Creanitine,Asam Urat)
HEMATOLOGI KHUSUS [ ] Bilirubin Direk
[ ] Anti Salmonella lg G [ ] NSE [ ] Pakat Lemak Lengkap )*

[ ] SI [ ] Anti Salmonella lg M/Tubex TF [ ] SCC (Serviks) (Chot,TG HDL,LDL)

[ ] Bilirubin Lengkap
[ ] TIBC [ ] Anti HIV [ ] Paket (AGD + Natrium/
(Bil Total+Direk+Indirek)
URINE
[ ] Transferin [ ] CD 4 Kalium/Chlorida)
[ ] Alkali Phospatase
[ ] Urine Lengkap
[ ] Feritin [ ] CD 8 [ ] Paket (Ns1 Ag+ Anti
[ ] Gamma GT
[ ] Glukosa / Reduksi
[ ] G6PD [ ] VDRL Dengue lg G / Lg M)
[ ] Cholinesterase (CHE)
[ ] Keton Urine
[ ] Analisa Hb (Elektroforesa) [ ] TPHA [ ] Paket Narkoba
[ ] Protein Electroforesa
[ ] Protein Kualitatif
[ ] Analisa Hb (HBLC) [ ] lg G Anti RB (PAP TB) (Amp, Morp, THC)
JANTUNG [ ] Protein Kuantitatif 24 Jam)*
[ ] Sel LE [ ] Chlamydia lg G [ ] Paket Enzim Jantung
[ ] LDH [ ] Sedimen
[ ] Coomb’s test [ ] Chlamydia lg M (LDH + CK + CKMB)
[ ] CK [ ] Mikro Albumin Urine
[ ] HBA2 [ ] Hellcobaeter Pylory lg G [ ] Paket (Feaces tengkap +
[ ] CKMB [ ] Test Kehamilan
[ ] Anti Bodi trombosit [ ] Hellcobacter Pylory lg M Darah Samar)
[ ] HBDH [ ] ACA lg G
[ ] Vitamin b 12 NARKOBA [ ] Paket TORCH
[ ] Troponin T [ ] ACA lgM
[ ] Faktor VIII [ ] Amphetamine (Toxoplasma lg G/M, Rubella
[ ] Troponin I [ ] Procalcitonin (PCT)
[ ] Faktor IX [ ] Morphine lg G/M CMV lg G/M, HSV l lg G/
[ ] CRP hs [ ] Anti Leptospira
[ ] Asam Folat [ ] ITHC (Marijuana) M,HSV ll lg G/M)
[ ] NT pro BNP [ ] lg E Total
[ ] Protein S [ ] Narkoba G Parameter
[ ] Hemocystein [ ] lg E Spesik
[ ] Viskositas Darah LAIN-LAIN
(tulis Rast yang dikehendaki) FAECES
[ ] Viskositas Plasma PANKREAS [ ] ................................................
[ ] Paeces Lengkap
[ ] Resistensi Osmotik [ ] Amilase HORMONAL [ ] ................................................
[ ] Darah Samar
HEMOSTASIS [ ] Lipase [ ] ................................................
[ ] Cortisol [ ] Analisa Faeces
[ ] BT / CT ELECTROLIT & GAS DARAH [ ] Estradiol [ ] ................................................
[ ] Rektal Swab
[ ] APTT [ ] FSH [ ] ................................................
[ ] Analisa Gas Darah (AGD)
[ ] PT / Protrombin Time [ ] LH CAIRAN TUBUH
[ ] Natrium / Kalium / Chlorida
[ ] TT / Tromnin Time [ ] Progesteron [ ] Analisa Cairan Acites
[ ] Calsium Total
[ ] Fibrinogen [ ] Prolaktin [ ] Analisa Cairan Otak
[ ] Calsium lon
[ ] D Dimer [ ] Testosteron [ ] Analisa Cairan Pleura
[ ] Magnesium
[ ] INR [ ] T3 [ ] Analisa Cairan Sendi Paraf Dokter
[ ] Phospor
[ ] Trombotest [ ] T4 [ ] Analisa Sperma
[ ] Agregasi Trombosit [ ] Free T3
IMUNOSEROLOGI
[ ] Anti Trombin 3 (At3) [ ] Free T4 PEMANTAUAN OBAT
HEPATITIS VIRUS
[ ] Digoxin
[ ] T3 Up take
KIMIA DARAH [ ] Anti HAV Total (dr. ............................................ )
[ ] Phenobarbital / Luminal
[ ] TSHs Tulis Nama Jelas
DIABETES [ ] Anti HAV lg M [ ] Aminphylin
[ ] Beta HCG Kuantitatif
[ ] Glucosa Sewaktu [ ] Anti Hbc [ ] Thephylin
[ ] Glucosa Puasa / Nuchter)* [ ] Anti Hbc lgM TORCH
HISPATOLOGI
[ ] Glucosa 2 Jam PP [ ] Anti Hbe [ ] Toxoplasma lg G
[ ] GTT Oral)* [ ] Anti Hbs [ ] Toxoplasma lg M [ ] PA. Jaringan Kecil
[ ] HbA1 C [ ] Anti Hbe [ ] Rubella lg G [ ] PA. Jaringan Besar Catatan :
[ ] C-Peptide [ ] Anti HCV Total [ ] Rubella lg M [ ] PAP Smear * Puasa 10 - 12 Jam
[ ] Keton Darah [ ] Anti HCV lgM [ ] CMV lg G [ ] Sitologi sampel ..................... ** Urine Tampung 24 jam
[ ] Fruktosamin [ ] HBsAg [ ] CMV lg M (tulis sampel yang diperiksa) (Konrmasi petugas laboratorium)
 RUMAH SAKIT
MURNI TEGUH
CILEDUG
Jl. HOS. Cokroaminoto (Ciledug Raya) No. 4A,
Kreo Selatan - Larangan, Tangerang 15156
Telp. 7371919 (Hunting), Fax No. 7371333
DAFTAR PEMERIKSAAN LABORATORIUM KIMIA DARAH
Unit Gawat Darurat 7371818 TGL : ........................................ 20 .......
TP B.T GO.T
NO. LAB NAMA PASIEN NO. R.M. RUANG / Y-GT FA CPK LDH CHL HDL TRY UREA CRT UA GDS GDN GDPP
ELEKTROLITE
DLL
KELAS A.L.B B.D GP.T Na K CL
E.LAB-01